Updates on Chronic Hypertension

Bruce-Harris Progress in OBGYN, 2020

Alan T.N. Tita, MD, PhD

John C. Hauth MD, Professor and Vice Chairman

Director, Center for Women’s Reproductive Health

Educational Objectives

● Distinguish ACOG, JNC 8 and AHA criteria for chronic HTN

● Describe the effects of pregnancy on BP

● Describe the maternal and neonatal morbidities of chronic HTN

● Outline a plan for IP and AP management of chronic HTN

● Describe 3 non-pharmacologic interventions to control chronic HTN

● Describe indications, risks and benefits of antihypertensive therapy in pregnancy

– CHAP Trial Update

Chronic Hypertension Chronic Hypertension - Adults

● Diagnostic criteria and prevalence of chronic hypertension– JNC 7/8 and 2017 ACC/AHA

● Treatment thresholds and types of treatment

JNC 8 Group: JAMA 2014Whelton PK, et al. J Am Coll Cardiol. 2018;71(19):e127-e248.

Whelton PK, et al. Hypertension. 2018;71(6):e13-e115.

2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

A comprehensive guideline that represents an update of JNC 7, not the focused JNC 8 (2014 Guideline)

Reclassification of high blood pressureBP treatment thresholds and ASCVD risk BP treatment goalsManagement of hypertension in patients with comorbidities

• New BP classification system

• New approach to hypertension treatment decisions– CVD risk estimation in addition to average BP

• Lower targets for BP during treatment

• Strategies to improve BP control

2017 Guideline for the Management of Patients with Hypertension

Categories of BP in Adults*

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.

BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as detailed in DBP,

diastolic blood pressure; and SBP systolic blood pressure.

BPCategory

SBP DBP

Normal <120 mm Hg

and <80 mm Hg

Elevated 120–129 mm Hg

and <80 mm Hg

Hypertension

Stage 1 130–139 mm Hg

or 80–89 mm Hg

Stage 2 ≥140 mm Hg

or ≥90 mm Hg

BP Classification (JNC 7/8 and ACC/AHA Guidelines)

SBP DBP

<120 and  <80

120–129 and <80

130–139 or 80–89

140–159 or 90‐99

≥160 or ≥100

2003 JNC7/2014 JNC8

Normal BP

Prehypertension

Stage 1 hypertension

Stage 2 hypertension

2017 ACC/AHA

Normal BP

Elevated BP

Stage 1 hypertension

Stage 2 hypertension

Stage 2 hypertension

• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions• Adults with SBP or DBP in two categories should be designated to the higher BP category 

Major areaof

difference

Whelton PK, et al. J Am Coll Cardiol. 2018;71(19):e127-e248. Whelton PK, et al. Hypertension. 2018;71(6):e13-e115.

Prevalence of Hypertension – 2017 ACC/AHA and JN7 Guidelines

Prevalence of hypertension, % Number with hypertension, millions

Muntner et. al. JACC. 2017Muntner, et. al. Circulation 2017

Whelton PK et al. Hypertension. 2017Whelton PK et al. JACC. 2017

Comparison of Prevalence using the 2003 JNC 7 and 2017 BP Guideline Definitions of Hypertension, by Race‐Ethnicity

Whelton PK et al. Hypertension. 2017Whelton PK et al. JACC 2017

50.1 M 70.8 M 10.7 M 14.3 M 2.9 M 4.4 M 6.9 M 11.3 M

Distribution of US Adults, by 2017 ACC/AHA BP Categories

Hypertension (prevalence = 45.6%)

Muntner et. al., J Am Coll Cardiol. 2018;71:109‐118/Circulation. 2018;137:109‐118

Normal BP Elevated BP

(>=<140/90)

Based on the NHANES 2011‐2014 (n=10,907 adults ≥20 y) 

(No BP meds)

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in AdultsA Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

BP THRESHOLDS AND RECOMMENDATIONS FOR TREATMENT OF

HYPERTENSION

Whelton PK, et al. Hypertension. (2017). Originally published November 13, 2017.

doi: https://doi.org/10.1161/HYP.0000000000000065

Whelton PK, et al. J Am Coll Cardiol. (2017). pii: S0735-1097(17)41519-1. doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

BP TREATMENT THRESHOLD AND THE USE OF ASCVD RISK ESTIMATION TO GUIDE DRUG TREATMENT OF HYPERTENSION

* ACC/AHA Pooled Cohort Equations to estimate 10-y risk of ASCVD. ASCVD was defined as a first nonfatal MI or CHD death, or fatal or nonfatal stroke among adults free of CVD.

Recommendations for BP Treatment Threshold and Use of ASCVD Risk Estimation* to Guide Drug Treatment of Hypertension

COR LOE RecommendationsI SBP:

A1. Use of BP-lowering medications is recommended for secondary

prevention of recurrent CVD events in patients with clinical CVDand average BP ≥130/80 mm Hg , and for primary prevention inadults with an estimated 10-year atherosclerotic cardiovasculardisease (ASCVD) risk ≥10% and average BP ≥130/80 mm Hg.

DBP:C-EO

I C-LD 2. Use of BP-lowering medication is recommended forprimary prevention of CVD in adults with no history ofCVD and with an estimated 10-year ASCVD risk <10%and average BP ≥140/90 mm Hg.

Benefits of using both BP and ASCVD risk assessment in determining BP thresholds for antihypertensive drug therapy

• Treatment is focused on patients most likely to have events

• More CVD events are prevented

• Larger absolute CVD risk reduction with treatment

• Lower number needed-to-treat to prevent one CVD event

• More quality-adjusted life years are saved

• Lower cost of care

SUMMARY: BP THRESHOLDS AND ASCVD RISK

BP thresholds and recommendations for treatment

Normal BP(BP

<120/80 mm Hg)

Elevated BP(BP 120-

129/<80 mm Hg)

Stage 1 Hypertension

(BP 130-139/80-89 mm Hg)

Stage 2 Hypertension

(BP >140/90 mm Hg)

BP THRESHOLDS AND RECOMMENDATIONS FOR TREATMENT

Non-pharmacologic

therapy (Class I)

Non-pharmacologic therapy and BP

lowering medication

(Class I)

Promote optimal lifestyle habits

(Class I)

Non-pharm-acologictherapy(Class I)

Clinical CVD or estimated 10 y 

ASCVD risk ≥ 10%

YesNo

Non-pharmacologic therapy and BP

lowering medication

(Class I)

Whelton PK, et al. Hypertension. (2017). Originally published November 13, 2017. doi: https://doi.org/10.1161/HYP.0000000000000065

Whelton PK, et al. J Am Coll Cardiol. (2017). pii: S0735-1097(17)41519-1. doi: 10.1016/j.jacc.2017.11.006. [Epub ahead of print].

Lifestyle

Intervention Dose

Impact on SBP

Hypertension Normotension

Weight loss Best goal is ideal body weight, but aim for 

at least a 1‐kg reduction in body weight for 

most adults who are overweight. Expect 

about 1 mm Hg for every 1‐kg reduction in 

body weight.

‐5 mm Hg ‐2/3 mm Hg

Healthy diet Consume a diet rich in fruits, vegetables, 

whole grains, and low‐fat dairy products, 

with reduced content of saturated and total 

fat.

‐11 mm Hg ‐3 mm Hg

Reduced intake of 

dietary sodium

Optimal goal is <1500 mg/d, but aim for at 

least a 1000‐mg/d reduction in most adults.

‐5/6 mm Hg ‐2/3 mm Hg

Enhanced intake of 

dietary potassium

Aim for 3500–5000 mg/d, preferably by 

consumption of a diet rich in potassium.

‐4/5 mm Hg ‐2 mm Hg

All 4 Recommendations COR:1; LOE:A

LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND

TREATMENT OF HYPERTENSION

Nonpharmacological Intervention

Dose

Effect on SBP

Hypertension Normotension

Physical 

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

‐5/8 mm Hg ‐2/4 mm Hg

Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10 

repetitions/set

‐4 mm Hg ‐2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min rest 

between exercises, 30%–40% 

maximum voluntary contraction, 

3 sessions/wk

● 8–10 wk

‐5 mm Hg ‐4 mm Hg

Moderation in 

alcohol intake

Alcohol consumption In individuals who drink alcohol, 

reduce alcohol to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

‐4 mm Hg ‐3 mm

LIFESTYLE MODIFICATION: THE CORNERSTONE FOR PREVENTION AND

TREATMENT OF HYPERTENSION

Both Recommendations COR:1; LOE:A

COR LOE Recommendation for Choice of Initial Medication

I ASR

For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs

CHOICE OF INITIAL MEDICATION

CHOICE OF INITIAL MONOTHERAPY VERSUS INITIAL COMBINATION DRUG THERAPY

COR LOERecommendations for Choice of Initial Monotherapy

Versus Initial Combination Drug Therapy*

I C-EO

Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target.

IIa C-EO

Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.

2017 ACC/AHA BP CPG• Lifestyle interventions are the cornerstone of BP management.• New thresholds for initiation of antihypertensive drug therapy in

stage1 hypertension, use of ASCVD risk estimation to determine whether to treat with:• Nonpharmacological therapy alone (“low” risk patients)• Antihypertensive drug therapy, in addition to

nonpharmacological therapy (“high” risk patients) • New target for BP control during treatment of hypertension.

SUMMARY

Hypertension in Patients With Comorbidities

2017 Hypertension Guideline Chronic Kidney Disease 

COR LOERecommendations for Treatment of Hypertension in Patients 

With CKD

I

SBP: 

B‐RSR Adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mm Hg.DBP: 

C‐EO

IIa B‐R

In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin‐to‐creatinine ratio or the equivalent in the first morning void]), treatment with an ACE inhibitor is reasonable to slow kidney disease progression.

IIb C‐EO

In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin‐to‐creatinine ratio in the first morning void]), treatment with an ARBmay be reasonable if an ACE inhibitor is not tolerated.

SR indicates systematic i

2017 ACC/AHA Hypertension Guideline: Diabetes Mellitus

COR LOERecommendations for Treatment of Hypertension in

Patients With DM

I

SBP:B-RSR

In adults with DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal of less than 130/80 mm Hg.

DBP: C-EO

I ASRIn adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective.

IIb B-NRIn adults with DM and hypertension, ACE inhibitors or ARBsmay be considered in the presence of albuminuria.

SR indicates systematic review.

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

I B-R

In black adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.

I C-LD

Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.

Strategies to Improve Hypertension Treatment and Control

• Adherence strategies

– Once daily dosing/combination pills

• Strategies to promote lifestyle modification

• Team-based care

– Health professionals: physicians, nurses, pharmacists

– Patient

– Staff: office staff and community health workers

– Others: spouse, relatives, friends

• Use (active) of EHR and Patient Registries

• Telehealth strategies

• Performance measures and quality Improvement initiatives

• Financial incentives

SHARED DECISION‐MAKING

BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s)BP

Threshold, mm Hg

BP Goal, mm Hg

GeneralClinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults)

≥130 (SBP) <130 (SBP)

Specific comorbiditiesDiabetes mellitus ≥130/80 <130/80Chronic kidney disease ≥130/80 <130/80Chronic kidney disease after renal transplantation ≥130/80 <130/80Heart failure ≥130/80 <130/80Stable ischemic heart disease ≥130/80 <130/80Secondary stroke prevention ≥140/90 <130/80Secondary stroke prevention (lacunar) ≥130/80 <130/80Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood

pressure.

SPRINT• Patients at ↑CV risk w/o DM (N>9000)

• Intensive tx of SBP (target, <120 mm Hg) vs. Std tx (target, <140 mm Hg).

• Median f/up of 3.26 years

• Cardiovascular events and death significantly lower with intensive treatment

• Sought to determine the impact of the 2017 ACC/AHA Guideline on reproductive-aged women

• Also analyzed 2011 – 2014 NHANES data

• Reproductive age defined as 20 – 44 years old

• An additional 4.5 million women had HTN by 2017 ACC/AHA compared with ACOG

CHTN in Pregnancy

Case 1

29 yo G1P0 at 13 weeks gestation

presents for a new obstetrics visit. Her

BP is 153 / 91. Only current medication

is her prenatal vitamin. Reports no

medical problems.

How would you treat her?

CHTN in Pregnancy● Preexisting

● Early pregnancy (<20 weeks)● Persists after delivery

● Distinct from:▬ Preeclampsia

▬ Gestational hypertension

CHTN in Pregnancy

● 2-6%→5-10% prevalence

● 4% at perinatal centers

● Common medical complication

▬ Prevalence rising

● Demographic shifts (age, obesity)ACOG: Obset Gynecol 2012Meis: AJOG 1998

Hypertension Nomenclature Stratified by 2019 ACOG, 2003 JNC7 and 2017

ACC/AHA Guidelines

<120/8

0

120-

129/<80

130-

139/80-89≥140/90

ACOG Normal>20 weeks GA =

GHTN

JNC7 Normal Pre-HTN HTN

ACC/A Elevated

CHTN in Pregnancy

Classified as

● Severe ≥160/110

● Mild 140-159/90-109

● >70-80%ACOG: Obset Gynecol 2019Caritis: NEJM 1998 (Database)

BP Measurement● Wide variability

● Standardization Sitting for several minutes

Appropriate size cuff

Arm cuff at heart level

Repeated measures (average)

Auscultatory vs. Oscillometric BP

Physiologic Changes● 40-50% increase in cardiac output

● 50% increase in blood volume

● 30% increase in red cell mass

● BP drops from 12 (8) to 18 weeks,

then rises to baseline by 28 weeks.

progesterone, relaxin

● Renal vasodilatation

Normal Variation in BP

● Normotensive pregnancies (NML) have lower SBP throughout

● SBP nadir in NML 21 (19 – 23) weeks

● SBP nadir earlier in HTN w/ PEC 21 (18 – 24) weeks

● In HTN w/o PEC, BP returns to pre-pregnancy after 25 (24 – 26) weeks.

Systolic BP Curves Diastolic BP Curves

CHTN in PregnancyWell-Established Complications

Outcome CHTN RR

● Preeclampsia 25.3% X3-10

● SGA 11.1% X2-3

● Abruption 1.5% X2-3

● Preterm birth 38.0% X3-4

PTB<35 week 18.1% X4-5

● Perinatal death 6.2% X3-5Bateman: AJOG 2012; Caritis: NEJM 1998; Gordon: JRM 2007

CHTN in PregnancyRare Complications

Outcome AOR

● Maternal death x3-5

● Pulmonary edema/CHF x6-12

● Ventilation x5-8

● Cerebrovascular accident x4-7

● Acute renal failure x10-16

● Stay >6 days x6-7

Bateman: AJOG 2012; Gordon: JRM 2007

Secondary Causes of CHTN (<10%)● Renal disease

– Glomerulonephritis– Interstitial nephritis– Glomerulosclerosis– IgA nephropathy– Polycystic kidneys– Renal artery stenosis– Renal transplant

● Collagen vascular disease– Lupus nephritis

– Scleroderma

– Periarteritis nodosaB. Sibai, MD

Secondary Causes of CHTN● Endocrine disorders

– Diabetes with vascular involvement

– Hyperthyroidism

• Graves disease

• Postpartum thyroiditis

– Adrenal adenomas

• Cushing disease

• Pheochromocytoma

• HyperaldosteronismB. Sibai, MD

CHTN - MANAGEMENT

Management of CHTN

● Evaluation pre-conception/first visit

● Etiology: Secondary?

● Presence of co-morbidity– Renal (routinely) - urine protein, s. creatinine

– Cardiac - EKG, Echo as indicated

– Others – tests as indicated

● Classify as mild or severe

● Lifestyle

● Medication, response, compliance– Type / # of drugs needed

B. Sibai, MD

CHTN - Maternal Monitoring● Weight gain (based on BMI)

● Sodium intake (max 2.4 g/d)

● Exercise/activity

● Compliance with visits & RX

● Progression to severe HTN

● Side effects of medications*

● SXs of severe disease**

● Diagnose superimposed preeclampsia

● Abruptio placentae *For those requiring medications

**Severe headaches, visual changes, epigastric pain, SOB B. Sibai, MD

CHTN - Fetal Monitoring

● Basic dating/anatomy ultrasounds

● Ultrasounds for growth & fluid– Q4-6 weeks in 3rd trimester

● Antenatal testing from 32/34 weeks

B. Sibai, MD

Example: Management Protocol● Moderate exercise ● Smoking cessation● Low dose aspirin (81mg daily)● Antihypertensive if severe (≥160/110)● Serial F/G ultrasound q4-6 from 28 weeks ● Weekly visits from 32-34 weeks

– Antenatal testing

● Delivery ≥39 weeks– 37 weeks or earlier if preeclampsia or SGA

● Prepregnancy medication PP

ACOG: ObstetGynecol 2019

Antihypertensive in Pregnancy

ACOG Recommendations:*

● Treat severe CHTN: ≥160/110

● 1st line options

– labetalol, nifedipine

*Moderate quality evidence / strong rec.

ACOG: Obstet Gynecol 2019

Antihypertensive in Pregnancy

ACOG Recommendations:*

● Mild CHTN: <160/110

● Withhold therapy

● Risks and benefits of discontinuing medication unclear

● Reasonable to discontinue or continue

* Low quality evidenceACOG: Obstet Gynecol 2019

Antihypertensive Drugs to Use in Pregnancy

Drug Usual dose( mg) Maxim. Dose( mg)

Labetalol 200 x bid/tid 2400

Nifedipine (LA) 10-30/d/bid 120

Methyldopa 500 bid/tid/qid 3000

Chlorothiazide 12.5-25/d 50

Nicardipine (SR) 60-120/d 240

Metroprolol (XL) 50-100/d 200

Hydralazine 10-25 x 4/d 300

Furosemide 20 x 2/d 80

CHTN in Pregnancy on Medications

Keep on same agents except for•ACE inhibitors

•ACE receptor blockers

•Atenolol

If Mild may D/C under observation•Reinstitute if severe HTN

ACE Inhibitors /ARBs in Pregnancy

Fetal Anomalies

FGR

Oligohydramnios

Neonatal renal dysfunction

Neonatal renal failure

Antihypertensive Therapy

● RCTs in Pregnancy

Few

Underpowered

Design limitations

Magee: BMJ 1999

● Systematic review

▬ Anti-hypertensive vs. none

● Mild CHTN only

● 7 trials

● N=623

Magee: BMJ, 1999

Selected Outcomes

Severe Hypertension

Perinatal mortality

Preeclampsia

Abruption

SGA

0.01 0.1 1 10

RR (95% CI)

0.3

0.4

0.7

0.4

1.3

Antihypertensive Therapy

Safety Concerns

● ↑Small gestational age (SGA)

– B blockers: OR 2.5 (1.02-5.9)

– Reduced MAP: Increasing SGAMagee: Eur J ObGyn 2000

Von Dadelszen: Lancet 2000

Summary● Treatment and BP control

● Effective for general population

● Uncertain benefits and safety in pregnancy

→ Conflicting recommendations

Antihypertensive Therapy for Mild CHTN during Pregnancy:

A Pragmatic RCT

NHLBI Cooperative AgreementChronic Hypertension and Pregnancy (CHAP) Project

CHAP Project Consortium

Primary Aim

To evaluate the benefits and safety of BP lowering therapy for mild CHTN

during pregnancy

Mild CHTN Pragmatic RCT

Mild CHTN

ActiveTarget <140/90

Usual Care (ACOG)

Target: <160/105

OutcomesSpecimens

OutcomesSpecimens

Severe HTN, Others

Sample size: N=2404

Adjusted*

90% power 1202/arm

CHAP Coverage

Future Study To evaluate the long-term impact of

CHTN therapy and Preeclampsia:

●Neurodevelopment

●Epigenetics

●Growth

Complex Contraception Clinic

● Tuesday morning.● Contraception consultation

– No ongoing Gyn care, no routine contraceptive care– No preconception counseling

● Same-day LARC available● UAB provider can place a referral using "Internal

Specialty Referral" order within Impact and click on the "GYN Complex Contraception Clinic."

● Outside providers may call 205-996-3130

Educational Objectives

● Distinguish ACOG, JNC 8 and AHA criteria for chronic HTN

● Describe the effects of pregnancy on BP

● Describe the maternal and neonatal morbidities of chronic HTN

● Outline a plan for IP and AP management of chronic HTN

● Describe 3 non-pharmacologic interventions to control chronic HTN

● Describe indications, risks and benefits of antihypertensive therapy in pregnancy

– CHAP Trial Update

Case 1

29 yo G1P0 at 13 weeks gestation

presents for a new obstetrics visit. Her

BP is 153 / 91. Only current medication

is her prenatal vitamin. Reports no

medical problems.

How would you treat her?

Questions?